Ask the Leadership: Update of the Clinical Practice Guidelines for the Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient

This column is dedicated to sharing the vast knowledge and opinions of the American Society for Metabolic and Bariatric Surgery leadership on relevant topics in the field of bariatric surgery.

This Month’s Interview with:

Daniel B. Jones, MD, MS, FACS
Dr. Jones is Professor of Surgery, Harvard Medical School; Vice Chair of Surgery, Office of Technology and Innovation; and Chief, Minimally Invasive Surgical Services, Beth Israel Deaconess Medical Center in Boston, Massachusetts

This month’s topic: An Overview of the 2013 Update of the Clinical Practice Guidelines for the Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient

FUNDING: No funding was provided in the preparation of this manuscript.

FINANCIAL DISCLOSURES: The author reports no conflicts of interest relevant to the content of this article.

Bariatric Times. 2013;10(7):20–21.

Dr. Rosenthal: What went into the 2013 Update of the Clinical Practice Guidelines? Who was involved? How was it compiled?

Dr. Jones: The 2013 CPG[1] builds upon the foundation set in the 2008 report.[2] An incredible amount of effort went into this project. It is a huge undertaking by dedicated people who wish to provide clean, honest, best-practice guidelines. The process of creating and publishing the updated CPG was as follows: Three editors (one from each society) and authors were selected. Once drafted, the editors, authors, and a separate group of reviewers evaluated and approved the paper. After that, the paper was circulated to the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), and the American Society for Metabolic and Bariatric Surgery (ASMBS) as well as other organizations involved in the care of bariatric patients (e.g., American College of Surgeons [ACS], Society of American Gastrointestinal Endoscopic Surgeons [SAGES], and the International Society for the Perioperative Care of the Obese Patient [ISPCOP]). All reviewed and approved it. We looked at all major publications to date and looked at each recommendation from 2008. We also looked at certain areas we knew we had to include or further revise, such as body mass index (BMI) range and new procedures.
Data were compiled and evaluated by surgeons, internists, and endocrinologists, who ultimately asked the question, “What do the data tell us?” Ultimately, the goal was to evaluate metrics and data to understand how we can do things better, which translates to better patient care.

Dr. Rosenthal: Why is it important to evaluate and publish clinical practice guidelines?

Dr. Jones: If no one ever read a paper or went to a meeting to discuss and evaluate surgery and patient care, our field would never get better. The purpose of these recommendations is to promote the best care for our patients.

Dr. Rosenthal: There were two new recommendations added to the CPG. One of these new recommendations, R30, suggests that patients undergo age- and risk-appropriated cancer screenings before bariatric surgery. Please discuss this new recommendation and other important items in the CPG that have been revised?

Dr. Jones: When the first CPG was compiled, we did not have enough evidence to make certain conclusions and recommendations. Most bariatric surgeons are aware that an individual with obesity has an increased risk of cancer. It is something that we have talked about for a decade. Now, there are enough studies that say we should be screening patients for cancer and thus add it to our list of recommendations.

Conversely, while compiling this installment of the CPG, we found that other therapies still do not have enough evidence to support their recommendations. One such example of this is endoluminal procedures and plication. We still consider these to be investigational. Five years from now, however, who knows? There may be sufficient evidence to recommend these procedures or there may be a new operation that is introduced.

Dr. Rosenthal: What does the CPG say about recommending bariatric surgery for the treatment of type 2 diabetes mellitus?

Dr. Jones: The whole field of bariatric surgery thinks of itself as not only a weight-reducing tool, but also a tool for improving health. That theme has not changed. If you look at the results of bariatric surgery, you will see metabolic improvements, such as improvements and even resolution of type 2 diabetes mellitus (T2DM). One of the things that did come up while compiling the CPG was the question of which operation is better for each sub-class of patients. We looked at all available data and decided that, at this time, we are not able to make such recommendations. The CPG does, however, provide benefits of each operation and states that the decision of which procedure an individual undergoes is largely at the discretion of the individual and the doctor performing the surgery. This conversation between doctor and patient should include a discussion of risk versus benefit. In selecting bariatric procedures, patients and surgeons are also tasked with considering the patient’s medical history and complications that may occur after surgery. For instance, alcohol addiction or transfer of addictions, marginal ulcers after Roux-en-Y gastric bypass (RYGB), the safety of using nonsteroidal anti-inflammatory drugs (NSAIDS), and possible slippages of adjustable gastric bands. It is not just about restriction. It is not just about malabsorption. Choosing which operation is right for one patient is just not that simple.

Dr. Rosenthal: What are some other highlights of the 2013 CPG?

Dr. Jones: One update to the CPG from 2008 is that the sleeve gastrectomy has become widely accepted as a primary bariatric operation and is no longer considered investigational.

Also, since 2008, enough evidence has emerged to suggest that patients with mild to moderate obesity (BMI 30–34.9kg/m2) and T2DM could benefit from early intervention with bariatric surgery. The United States Food and Drug Administration (FDA) approved the use of laparoscopic adjustable gastric banding (LAGB) for patients with a BMI of 30–35kg/m2 with T2DM or other obesity-related conditions. The International Diabetes Federation (IDF) has also incorporated this position.

Dr. Rosenthal: Do you think those in the field closely follow these guidelines?

Dr. Jones: I think these are the best recommendations we have to date and they are certainly the most current. These guidelines get you thinking, “Is what I am doing providing the best care for my patients?” and, “Am I confident that what I am doing is right?” I think that when presented with recommendations, people are receptive to the “best way.”

It is important to note that not all medical fields compile clinical practice guidelines, which I think is a credit to our field. The idea of looking at data together and evaluating benefits, costs, and outcomes and sharing with the field helps us to achieve the best possible outcomes together. Of course, everyone has different experiences that may drive their decisions and preferences. For instance, surgeons may have different answers to the question, “Do you put a drain in after RYGB?”

Dr. Rosenthal: Do you feel these guidelines are important? Do they show the evolution of bariatric surgery?

Dr. Jones: Yes, the clinical practice guidelines are important. First, we should all acknowledge the people who gave us the first CPG in 2008 and next, acknowledge the work of AACE, TOS, and ASMBS as leaders in publishing and disseminating these guidelines. The CPG guidelines help us to evaluate and discuss better, safer, and more cost-effective ways to treat the disease of obesity. We are learning to ask better questions and demand better answers, which is the process for providing better care. Charles Sidney Burwell, Dean of Harvard University from 1935 to 1949 said, “Half of what we are going to teach you is wrong, and half of it is right. Our problem is that we don’t know which half is which.”[3] Things we learn will either strengthen or refute ideas.

We need to applaud these three societies for looking for the truth. In doing so, as a profession we will be closer to knowing which recommendations are correct, and thus, help provide the best care. I am very proud of AACE, TOS, and ASMBS for supporting this initiative and helping all of us to become better surgeons and caregivers to our bariatric patients.

Dr. Rosenthal: Would you encourage readers of Bariatric Times to read the 2013 CPG?

Dr. Jones: Yes. Sure, it is a tough read, but when you look through it it is important to note that everything that is there was included because someone thought it was important and convinced someone else is was important. Everyone was in agreement to these guidelines being the strongest statements. The tables included are also helpful. For instance, the CPG includes tables outlining preoperative and postoperative checklists for bariatric surgery.
All readers of Bariatric Times—surgeons, nurses, dieticians, support group leaders, etc.—need to sit down on a Sunday afternoon and decide whether they want to sign on to these recommendations or look at doing something different.

Dr. Rosenthal: Dr. Jones, thank you for taking the time to speak with us.

References
1.    Mechanick JI, Youdim A, Jones DB, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient-2013 update: cosponsored by american association of clinical endocrinologists, the obesity society, and american society for metabolic and bariatric surgery. Endocr Pract. 2013;19(2):337–372.
2.    Mechanick JI, Kushner RF, Sugerman HJ, et al. American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Surg Obes Relat Dis. 2008;4(5 Suppl):S109–S184.
3.    Harvard Medical School. Past Deans of the Faculty of Medicine
http://hms.harvard.edu/about-hms/facts-figures/past-deans-faculty-medicine Accessed May 16, 2013.

Category: Ask the Leadership, Past Articles